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Signing Instructions

Instructions
U.S. Department of State

REQUEST FOR APPROVAL UNDER THE "GENERIC CLEARANCE
FOR THE COLLECTION OF ROUTINE CUSTOMER FEEDBACK"
OMB CONTROL NUMBER: 1405-0193
Federal Feedback Button Pilot

Title of Information Collection
Purpose

The Office of Management Budget (OMB) and the General Service Administration (GSA) are seeking to pilot the Federal
Feedback Button Initiative at federal agencies with a high volume transactions with the public and a commitment to continuous
improvement.
The purpose of the Feedback button is to collect customer feedback and provide:
-Agencies with the information needed to improve processes and delivery of services
-The Executive Branch with insight into best practices and areas of improvement
-Citizens with transparency around the quality provided

Description of Respondents

Passport applicants who wish to provide feedback about their application process.

Type of Collection: (Check one)
Customer Comment Card/Complaint Form

X Customer Satisfaction Survey

Usability Testing (e.g., Web site or Software)

Small Discussion Group

Focus Group

Other

Certification
I certify the following to be true:
1. The collection is voluntary.
2. The collection is low-burden for respondents and low-cost for the Federal government.
3. The collection is non-controversial and does not raise issues of concern to other Federal agencies.
4. The results are not intended to be disseminated to the public.
5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.
6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with
the program in the future.
Name (Last, First, MI)

Jazavac
Signer Email Address

jazavacb@state.gov
DS-4183
04-2015

Title

Benjamin

Forms Program Manager
Date (mm-dd-yyyy)

06-05-2015
Page 1 of 2

Instructions
TO ASSIST REVIEW, PLEASE PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS.
Personally Identifiable Information
1. Is personally identifiable information (PII) collected?
a. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974?
2. If Applicable, has a System of Records Notice been published?

Yes

X No

Yes

No

Yes

X No

Yes

X No

Gifts or Payments
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?
BURDEN HOURS
Category of Respondent

Number of Respondents Participation Time (Minutes)

Individuals or Households

Totals

Burden Hours

76,000

0.17

215.33

76,000

0

215.33

FEDERAL COST
The estimated annual cost to the Federal government is

$56,160.00

IF YOU ARE CONDUCTING A FOCUS GROUP, SURVEY, OR PLAN TO EMPLOY
STATISTICAL METHODS, PROVIDE ANSWERS TO THE FOLLOWING QUESTIONS
The selection of your targeted respondents
1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for
selecting from this universe?
Yes X No
If the answer is yes, please provide a description of both below (or attach the sampling plan). If the answer is no, please provide a description
of how you plan to identify your potential group of respondents and how you will select them.

The respondents will be passport applicants, who wish to provide their feedback (voluntarily) about their experience at our
Passport Agencies.

Administration of the Instrument
1. How will you collect the information? (Check all that apply)
Web-based or other forms of Social Media
Telephone

X In-person
Mail

X Other, Explain On site Kiosk

2. Will interviewers or facilitators be used?

DS-4183

Yes

X No

PLEASE MAKE SURE THAT ALL INSTRUMENTS, INSTRUCTIONS, AND SCRIPTS ARE SUBMITTED WITH THE REQUEST.
Page 2 of 2

Return to Form
U.S. Department of State

REQUEST FOR APPROVAL UNDER THE "GENERIC CLEARANCE
FOR THE COLLECTION OF ROUTINE CUSTOMER FEEDBACK"
OMB CONTROL NUMBER: 1405-0193
INSTRUCTIONS
Title of Information Collection: Provide the name of the collection that is the subject of the request. (e.g., Comment card for soliciting feedback
on xxxx.)
Purpose: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include
this in your explanation.
Description of Respondents: Provide a brief description of the targeted group or groups for this collection of information. These groups must
have experience with the program.
Type of Collection: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each
instrument.
Certification: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be
disapproved.
Personally Identifiable Information: Provide answers to the questions.
Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.
Burden Hours:
Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or
Households; (2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be
selected.
Number of Respondents: Provide an estimate of the number of respondents.
Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g., fill out a survey or participate in
a focus group)
Burden: Provide the Annual burden hours: Multiply the Number of responses by the participation time, and then divide by 60.
Federal Cost: Provide an estimate of the annual cost to the Federal government.
If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:
The selection of your targeted respondents: Please provide a description of how you plan to identify your potential group of respondents
and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.
Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether
there will be interviewers (e.g., for surveys) or facilitators (e.g., for focus groups) used.
Please make sure that all instruments, instructions, and scripts are submitted with the request.

DS-4183
06-2011

Instruction Page 1 of 1